Health Policy Research

Reports

• “Strategies for Reining in Medicare Spending Through Delivery System Reforms: Assessing the Evidence and Opportunities.” Randall Brown, September 2009. This paper reviews proposed reforms to strengthen Medicare’s long-term fiscal outlook. Looking beyond provider payment reductions, the author assesses leading strategies to improve quality of care and efficiency within Medicare as well as the overall health care system. The paper argues that many of the most prominent proposed reforms are not likely to achieve savings for Medicare in the next 10 years, but identifies approaches that hold real promise for generating savings by either reducing chronically ill beneficiaries’ need for expensive services or changing providers’ practices in ways that decrease unnecessary procedures and inefficiencies. A companion paper synthesizes evidence on cost-effective interventions, identifies issues to resolve for ongoing research, and recommends care coordination policies supported by available evidence. Read more about Mathematica's evaluation of the Medicare Coordinated Care Demonstration. 
• “Enhanced Primary Care Case Management Programs in Medicaid: Issues and Options for States.” James Verdier, Vivian Byrd, and Christal Stone, September 2009. This report examines how five states—Oklahoma, North Carolina, Pennsylvania, Indiana, and Arkansas—have enhanced their Medicaid primary care case management (PCCM) programs to provide more intensive care management and care coordination for high-need beneficiaries, improve financial and performance incentives for primary care providers, and increase use of performance and quality measures. The report is aimed at states that may not have the option of contracting with fully capitated at-risk managed care organizations (MCOs), or that may want to use PCCM programs as an option for beneficiaries and as a source of competition and comparison for MCOs.
• "Evaluation of Mountain Health Choices: Implementation, Challenges, and Recommendations." Michael Hendryx, Carol Irvin, James Mulligan, Sally Richardson, Johanna S. Beane, and Margo Rosenbach, August 2009. In 2006, West Virginia established Mountain Health Choices, a key component of the state’s Medicaid redesign efforts. The program offers low-income parents and children the choice of two benefit plans. Beneficiaries receive additional benefits when they follow basic rules that are designed to increase personal responsibility and strengthen their relationship to a medical home. This report shows that despite widespread support for the goals of the program, Mountain Health Choices has yet to realize its potential. Many people in the state believe the program may have difficulty achieving its goals because of implementation challenges. For example, beneficiaries and providers say they have not been receiving the continuous education and outreach they need to help beneficiaries make an informed choice of benefit plans. The authors recommend a series of improvements to enhance the program, including immediate and meaningful rewards for positive behavior changes.
• "Recommendations of the Special Commission on the Health Care Payment System." Deborah Chollet, Robert Schmitz, Tim Lake, Michael Bailit, and Margaret Houy, July 2009. The Massachusetts Special Commission met from January to July 2009 to investigate reforming and restructuring the state’s health care system to provide incentives for efficient and effective patient-centered care and reduce variations in the quality and cost of care. This report details the principles that guided the Special Commission, reports input from key stakeholders, assesses alternative payment approaches, and reports the Special Commission’s recommendations for payment policy and implementation.
• “Strategies for Simplifying the Medicare Advantage Market.” Marsha Gold, July 2009. Medicare beneficiaries have at least 40 Medicare Advantage (MA) plan options to choose from this year. While some policymakers favor a robust marketplace, others argue that fewer plan offerings, or more transparent differences across plan designs, would help beneficiaries choose plans most likely to meet their individual needs. This report uses new data to examine a range of policy options that would simplify choices for Medicare beneficiaries, including changes recently proposed by the Obama Administration. It also assesses the implications for beneficiaries and the potential change in the number of plan offerings as a result of each option. For example, requiring each plan to have at least 100 enrollees would affect an estimated 4.2 percent of current MA enrollees and reduce the average number of plans available to each beneficiary from 43 to 32.
• “Final Evaluation Report: Best Practices for Enrolling Low-Income Beneficiaries into the Medicare Prescription Drug Benefit Program.” Mary Laschober and Jung Yee Kim, February 2009. In 2006, optional coverage for outpatient prescription drugs (Medicare Part D) was added to the Medicare program, along with a low-income subsidy program to help beneficiaries with limited incomes pay for Part D out-of-pocket expenses. Mathematica’s study suggests the following best practices for enrolling these beneficiaries: use high-quality lists of leads to identify potential beneficiaries; identify and educate beneficiaries by reaching out to them through their daily activities; tailor messages to local markets and media; time community outreach to coincide with already planned activities; provide one-on-one assistance; use counselors that beneficiaries trust; and provide assistance in beneficiary’s primary language.

Journal Articles

• "Temporal Trends in Anti-Diabetes Drug Use in TRICARE Following Safety Warnings in 2007 About Rosiglitazone." Kate Stewart, Brenda Natzke, Thomas Williams, Elder Granger, S. Ward Casscells, and Thomas Croghan, Pharmacoepidemiology and Drug Safety (subscription required), November 2009. In 2007, highly publicized warnings suggested rosiglitazone, a drug used to treat type 2 diabetes, may be associated with an increased risk of heart attack and cardiovascular-related death. This article details the response to these warnings by analyzing anti-diabetes drug use before and after the 2007 warnings in the military health system. We found that the total number of prescriptions for all anti-diabetes medications remained constant before and after the warnings, although prescriptions of rosiglitazone declined by more than 50 percent after the warnings.
• "State Variation in Out-of-Home Medicaid Mental Health Services for Children and Youth: An Examination of Residential Treatment and Inpatient Hospital Services." Jonathan Brown, Brenda Natzke, Henry Ireys, Mathew Gillingham, and Morris Hamilton, Administration and Policy in Mental Health and Mental Health Services Research (subscription required), August 2009. Using Medicaid data from 2003, this article describes the demographics and diagnoses of youth under 22 receiving mental health services in general and psychiatric hospitals, psychiatric residential treatment facilities, and other residential treatment settings. The research found that treatment stays and costs in these facilities varied considerably from state to state, findings which may call for more research on state service systems and Medicaid policies.
• "Tools for Developing, Implementing, and Evaluating State Policy." Bernadette Ford Lattimore, So O’Neil, and Melanie Besculides, Preventing Chronic Disease, April 2008. The Division for Heart Disease and Stroke Prevention of the Centers for Disease Control and Prevention (CDC) funds heart disease and stroke prevention programs to help states develop, implement, track, and promote public policy that addresses cardiovascular disease. In this article, learn how Mathematica conducted the Heart Disease and Stroke Prevention Policy Project for the CDC and developed an online database of cardiovascular disease prevention policies and a mapping application for participating states. We discuss the methods for developing these tools, lessons learned, and how these tools can help states develop and implement heart disease and stroke prevention policies and programs.
• "The Impact of Malpractice Liability Claims on Obstetrical Practice Patterns.” Gilbert Gimm. HSR: Health Services Research, February 2010. Medical malpractice in obstetrics continues to attract scrutiny. This paper examines the impact of physicians’ malpractice claims on Caesarian section rates and physician delivery volume in Florida between 1992 and 2000. The author found that malpractice claims led to a small reduction in physician delivery volume but did not significantly impact C-section rates. Physicians performed six fewer inpatient deliveries three years after a malpractice claim closed, while those with malpractice awards of $250,000 or more performed, on average, 14 fewer deliveries, about 10 percent of a physician’s annual delivery volume. While patient access to obstetrical care in Florida does not appear to be compromised by malpractice claims, this finding suggests that tort reforms with damage caps of $250,000 may limit reduction in average delivery volume.
• "Implementation of Mental Health Parity: Lessons From California." Margo L. Rosenbach, Timothy K. Lake, Susan R. Williams, and Jeffrey A. Buck, Psychiatric Services, December 2009. Reprinted with permission from Psychiatric Services (Copyright 2009). American Psychiatric Association. In 2000, California legislated parity coverage for mental health care. This article reviews the experiences of state health plans, providers, and consumers between 2000 and 2005 in implementing parity and discusses implications for the 2008 federal parity law. California’s experiences suggest that federal policymakers should consider monitoring health plan performance related to access and quality, in addition to monitoring coverage and costs; examining the breadth of diagnoses covered by health plans; and mounting a campaign to educate consumers about their insurance benefits.
• "Relationship Between Alcohol Use and Violent Behavior Among Urban African American Youths from Adolescence to Emerging Adulthood: A Longitudinal Study." Yange Xue, Marc A. Zimmerman, and Rebecca Cunningham, American Journal of Public Health, November 2009. This study examined developmental trajectories of alcohol use and violent behavior among urban African American youth and the longitudinal relationship between these behaviors from adolescence to emerging adulthood. The sample included 649 African American youth (49 percent male) followed for eight years. Violent behavior peaked in middle to late adolescence and declined thereafter, whereas the frequency of alcohol use increased steadily over time. These trajectories varied according to gender. Among both male and female participants, early violent behavior predicted later alcohol use, and early alcohol use predicted later violent behavior. Moreover, changes in one behavior were associated with changes in the other.
• "Racial/Ethnic and Socioeconomic Disparities in Access to Care and Quality of Care for U.S. Health Center Patients Compared with Non-Health Center Patients." Leiyu Shi, Jenna Tsai, Patricia Collins Higgins, and Lydie A. Lebrun, Journal of Ambulatory Care Management (subscription required), October/December 2009. This study compares racial/ethnic and socioeconomic disparities in access to care and quality of care for U.S. health center patients and non-health center patients. Data for the study came from the 2002 Community Health Center User Survey and the 2003 National Healthcare Disparities Report. Results show that health center patients experience fewer racial/ethnic and socioeconomic disparities in access to care and quality of care, compared with non-health center patients nationally.

Issue Briefs

• "Using Professionally Trained Interpreters to Increase Patient/Provider Satisfaction: Does It Work?" Ann Bagchi, Stacy Dale, Natalya Verbitsky-Savitz, and Sky Andrecheck, Trends in Health Care Quality, Issue Brief 6, February 2010. Communication between patients and providers is critical in hospital emergency departments, but most interpretive services for non-English speakers—often provided via telephone or ad hoc by untrained bilingual staff or family member(s)—vary in quality. This issue brief identifies how professional interpreters improve communication and, consequently, patient and provider satisfaction in the emergency department.
• "Episode-Based Payments: Charting a Course for Health Care Payment Reform.”  Hoangmai Pham, Paul Ginsburg, Timothy Lake, and Myles Maxfield, Policy Analysis, January 2010. A new policy analysis funded by the National Institute for Health Care Reform examines the appeal of episode-based payments as an alternative to the current fee-for-service model. The method bundles payment for some or all services for a specific health condition or event over a certain period of time. Success depends upon defining what constitutes an episode of care; establishing episode-based payment rates and identifying providers to receive these payments; ensuring compatibility with other proposed payment reforms; and implementing pilot projects using a narrow set of health conditions, patients, and providers.
• “Accountable Care Organizations: Will They Deliver?” Marsha Gold, January 2010. This brief examines accountable care organizations—groupings of diverse health care providers that care for a group of people and aim to create a cohesive framework, encourage accountability, and create incentives and rewards to providers that focus on the overall scope of patient care. It examines ACOs’ role in improving, integrating, and coordinating care delivered by multiple providers. It also places ACOs in the historical context of health care reform in the United States to draw lessons from history on the challenges to be encountered and potential strategies for making ACOs more successful.
• "Practical Lessons for Health Reform from the Military Health System." Trends in Insurance Coverage #6, Thomas Croghan, Kristen Purcell, and Kate Stewart, November 2009. Many current health reform proposals focus on universal coverage, insurance reform, and cost control. This brief presents results from studies of the military health system that have timely implications for health care reform. The findings suggest universal coverage with comprehensive health insurance benefits is unlikely to solve many of the problems in our current system without other changes. The research indicates that other actions, such as strengthening primary care and public health initiatives, will also be necessary to solve these problems.
• “Plan Availability and Premiums.” Medicare Advantage 2010 Data Spotlight, Marsha Gold, Dawn Phelps, Tricia Neuman, and Gretchen Jacobson, November 2009. This summary provides an overview of the Medicare Advantage (MA) marketplace and highlights key changes between 2009 and 2010. On average, Medicare beneficiaries will be able to choose from more than 30 MA plans in 2010—in addition to the traditional Medicare program. Beneficiaries who decide to remain in their same MA plan can expect premium increases of 32 percent, on average. The total number of plans declined from 2009 to 2010 as a result of efforts by the Centers for Medicare & Medicaid Services to simplify the marketplace and strategic decisions by insurance companies.
• “Early Implementation Experiences of State MFP Programs.” National Evaluation of the Money Follows the Person Demonstration Grant Program: Reports from the Field #3, Noelle Denny-Brown and Debra J. Lipson, November 2009. The Money Follows the Person (MFP) demonstration is the most ambitious program to date aimed at helping Medicaid enrollees transition from long-term care institutions to the community. This report, the third in a series presenting findings from Mathematica’s evaluation of the MFP program, describes states’ early implementation experiences and state transition activity as of December 2008. It also discusses the challenges that states have encountered in trying to launch the program, and implications for making fundamental changes in the long-term care system.

Other

• Massachusetts has been a leader in experimenting with and implementing health care reform initiatives. The Massachusetts Special Commission on the Health Care Payment System recently endorsed recommendations for improving the quality of health care by dramatically changing the way patients pay for care. Staff from Mathematica, led by Deborah Chollet, Bob Schmitz, and Tim Lake, drafted the report and background material for the commission. Read about the recommendations and access the full report. (See page 73 for Mathematica’s role; Appendix C contains the memos we prepared.) The report was covered in the New York Times, Wall Street Journal, Boston Globe, and other media.
• “Chartbook: Medicaid Pharmacy Benefit Use and Reimbursement in 2005.” Ann Bagchi, James Verdier, and Dominick Esposito, June 2009. This chartbook highlights national and state-by-state data on Medicaid prescription drug use and expenditures for 2005 by beneficiary characteristics (age, sex, and race), basis of eligibility (children, adults, disabled, and aged), and type of drug (brand vs. generic, top 10 drug groups, top 7 therapeutic categories, and drugs excluded by statute from Medicare Part D). Separate graphs highlight Medicare-Medicaid dual eligibles, whose drug coverage shifted to Medicare in 2006, and nondual beneficiaries, who continue to receive their drug coverage from Medicaid. The detailed state-by-state and national tables for 1999 and 2001-2005 on which the chartbook is based (statistical compendiums) are on the Centers for Medicare & Medicaid Services website.
• Recent media coverage, including a New Yorker article (June 1, 2009) on “The Cost Conundrum” has policymakers concerned about how per-capita health care costs vary widely across the country, what to make of this variation, and how to respond as health reform and Medicare spending dominate the health policy debate. For Robert Wood Johnson Foundation's Synthesis Project, Marsha Gold sought to help policymakers better understand these issues. Her review confirms the existence of wide variations in Medicare per capita spending across the nation that appear connected with differences in use of health services and not associated with improvements in outcomes. Framing an effective response is challenging because any solution will create winners and losers, and a lot remains unknown about why areas that appear to be similar actually differ. Simply lowering payments to high cost areas without changing the underlying dynamics of care delivery will not necessarily translate into more effective care. Policies that modify the culture of medical practice, the financial incentives embedded in the system, and the way doctors communicate with one another are likely to be critical to having all patients, wherever they live, gain access to appropriate care.